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RC-16-837 u Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)785-2204 Fax:(305)756-8972 Inspection Number: INSP-268992 Permit Number: RC-3-16-837 Scheduled Inspection Date: October 17,2016 Permit Type: Residential Construction Inspector. Mesa, Michel Inspection Type: Final Owner. NETKIN,ROBERT AND MELISSA Work Classification: Alteration Job Address:1266 NE 94 Street Miami Shots,FL 33138- . Phone Number (305)965-511.0 Parcel Number 1132050100170 Project <NONE> Contractor NUSPACE NETWORK, LLC Phone: (305)945-3919 Building Department Comments REPLACE EXISTING 1000 SF FLOORING WITH Infractio - ommen PORCELAIN. RELOCATE EXISTING REFRIGERATOR INSPSCTOR COMMENTS False ELECTRICAL OUTLET AND REPLACE KITCHEN CABINET Inspector Comments Passed Failed Correction Needed Re-inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid G October 14,2016 For Inspections please call: (305)7624949 Page 39 of 43 ei!°'1s t Miami Shores Village f � �#ttitltl�al�$ r �tion 10050 N.E.2nd Avenue NE �1lOrk�,S'slli��? Altl�lr��►n •• "' Miami Shores,FL 33138-0000 PBritSPBW Phone: (305)795-2204 eiCi'4111 01� Expiration: 1011112016 t� tst, Exp. Project Address Parcel Number Applicant 1266 NE 94 Street 1132050100170 ROBERT AND MELISSA NETKIN ?. Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell ROBERT AND MELISSA NETKIN 1266 NE 94 Street (305)965-5110 MIAMI SHORES FL 33138-2947 Contractor(s) Phone Cell Phone Valuation: $ 12,000.00 NUSPACE NETWORK,LLC (305)945-3919 (786)417-3610 .... . . ........ Total Sq Feet: 1000 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final PE Certification Date Denied: Window Door Attachment Type of Construction:REPLACE EXISTING 1000 SF FLOC Occupancy: Framing Stories: Exterior: Insulation Front Setback: Rear Setback: Drywall Screw Left Setback: Right Setback: Fill Cells Columns Bedrooms: Bathrooms: Window and Door Buck Plans Submitted:Yes Certificate Status: Review Planning Certificate Date: Additional Info: Review Plumbing Review Electrical Bond Retum: Classification:Residential Review Electrical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Building CCF $7.20 Review Structural DBPR Fee Invoice# RC-3-16-59196 Review Mechanical $5.40 04/14/2016 Check*:10234 $349.00 $50.00 DCA Fee $5.40 Education Surcharge $2.40 03/29/2016 Check* 10217 $50.00 $0.00 Permit Fee $360.00 Scanning Fee $9.00 Technology Fee $9.60 Total: $399.00 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is rate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-na ctor to do the work stated. April 14, 2016 Authorized Signature:Owner / Applicant / / Agent Date Building Department Copy April 14,2016 1 Miami Shores VillageT,p_y,�� -:_ '` Building Department MAR 29 2016 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(30S)762-4949 FBC 20 BUILDING Master Permit No. RC (6-03?� PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 4, 66 l U e `�y � City Miami Shores County: Miami Dade Zip: 33�•�O Folio/Parcel#:t1-3 2 0 S^ 0<U - 0/-70 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: l FFE: �^ OWNER:Name(Fee Simple Titleholder): O S P� ' v 4/� Phone#: ®J^` ���^ ��J`, Address: C G Y r City: lAGJ�l � vve State: Zip: Tenant/Lessee Name: Phone#: Email: 1I Ju Company Name: //" .S140fiQ , "1 ce eitAfo`�1` Phone#:0T- ?Y5--2'7-,/7 Address: n l S� Pv� e 1v G 33/3o City: �LI.� State: Zip: Qualifier Name: ,411Y -4)14A 1.4t4d Phone#20-1 - State Certification or Registration#: C_ G C 0 6 a t<e Certificate of Competency#: DESIGNER:Architect/Engir(eer: Phone#: Address City: State Zip: Value of Work for this Permit:$ 1)/ Q 0® Square/Linear Footage of Work: ZO 00 Sq � Type of Work: ❑ Addition 2- Alteratii ❑ New / ❑ Repair/Rept ce ❑ Demolition scription WC f Work 4ce '9C t S(1µ 16,00 S ^ r/610 �K of t�l potIcelco pe w: C'K I rif 14 etyr ieo oV (? ecVrCA u e QK DePT4 c C�pd\' CAStie Specify color of color thru tile: W 0 0 4 14 y ov CC' o (N Submittal Fee$ U0• 03 Permit Fee$ J+od ' CCF$ - • CO/CC$ Scanning Fee$ Radon Fee$ 1-4 P D13P'R$$ Notary$ Technology Fee$ q 60 Training/Education Fee$ 2 T Double Fee$ Structural Reviews$ Bond$ Z 3 00 Of �y�_ TOTAL FEE NOW DUE$ —I - (Revised02/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done In compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULTMHTH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.i Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of t o ce of commencement must be posted at the job site for the first inspection which occurs s en (7) days a building permit is Issued. n the absence of such posted notice, the inspection will not be approve n r ns n fee will be charged. A r i Signature Signature OWNER or AGENT CON RACTOR The foregoing instrument was acknowledged before me this The foregoing strument s acknowledged before m/e'this k day of 4A e-C4 .20 1,G by _day of .20 .by .who is personally known to .who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY P NOTARY PUBLIC: - i nE J11AN auw...,. Sign: _�. .•= Notar _ Sign: *S P° JUAM At RmTn Y Comm Ex ate o/Fjori Public-State of Florida Print: pJres Print: Seal. °n FF 199 Seal,CUIa ,, Commission#FF 1"I Ulf 95 ss*****ss*s*s**sss*********s***s**ss***s*s****s*s*sss**s*s*s***ssss*sss********s***as**********s*s*ss*ss**ss APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 4 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 RUMIANO, MARIO LIONELLO NUSPACE NETWORK, LLC 40 SW 13TH STREET SUITE 101 MIAMI FL 33130 Congratulations! With this license you become one of the nearly _ one million Floridians licensed by the Department of Business and - Professional Regulation. Our professionals and businesses range ,a- ,� STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, II DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. 4�..' PROFESSIONAL- REGULATION Every day we work to improve the way we do business in order to CGCO62162 ISSUED: 09/14/2014 serve you better. For information about our services,please log onto - www.myfloridalicense.com. There you can find more information CERTIFIED GENERAL CONTRACTO_ R about our divisions and the regulations that impact you,subscribe RUMIANO,MARIO LIONELLO to department newsletters and learn more about the Department's initiatives. NUSPACE NETWORK,LLC Our mission at the Department is:License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your - customers. Thank you for doing business in Florida, IS CERTIFIED under 6e-provisions of Ch.489 FS. and congratulations on your new license! Expirapon We :AUG 31.2016 L1409140003011 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGCO62162 ., The GENERAL CONTRACTOR Named below IS CERTIFIED aA ` Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 RUMIANO, MARIO LIONELLO NUSPACE NETWORK, LLC 40 SW 13TH STREET OFFICE 101 r MIAMI FL 33130 ■ ISSUED: 09/14/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1409140003011 001926 Local Business Tax Receipt Miami-Dade County, State of Florida —THIS IS NOTA BILL — DO NOT PAY LBT 6320899 BUSINESS NAME&OCATION RECEIPT NO. EXPIRES NUSPACE NETWORK LLC RENEWAL SEPTEMBER 30, 2016 40 SW 13 ST 101 6887373 Must be displayed at place of business MIAMI FL 33130 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC."o YPE OF BUSINESS NUSPACE NETWORK LLC 207 ADMIN OFFICE/OPERATION CTR PAYMENT RECEIVED BY TAX COLLECTOR Employee(s) 1 $45.00 07/06/2015 CREDITCARD-1 5-033248 This local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit,or a certification of the holder's qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec Ba-276. For more information,visit www.miamidade.covltaxcollector 001392 Local Business Tax Receipt Miami-Dade County, State of Florida THIS IS NOTA BILL — DO NOT PAY �LBTJ 7109879 BUSINESS NAME&OCATION RECEIPT NO. EXPIRES NUSPACE NETWORK LLC wiNEWAL SEPTEMBER 30, 2016 DOING BUS IN DADE CO 6729380 Must be displayed at place of business MIAMI FL 33000 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED NUSPACE NETWORK LLC 196 GENERAL BUILDING CONTRACTOR BY TAX COLLECTOR Worker(s) 1 CGC062162 $75.00 07/06/2015 CREDITCARD-15-033248 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit,or a certification of the holder's qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sac Ba-276. For more information.visit www miamidede aovltaxcollegm ' Date CERTIFICATE OF LIABILITY INSURANCE 3/17/2016 producer. Plymouth Insurance Agency Tbft cite Is Issued as a maser of Information only and confers no 2739 U.S. Highway 19 N. rl"upon me certificate Bolder. This Certifkxrte does not amend,eidand Holiday, FL 34691 or after the coverer afforded by the poples below. (727)938-5562 1 Insurers Affording Coverage NAIC# Irmured: South East Personnel Leasing, Inc. &Subsidiaries Insurer A. Uon Insurance Company 11075 2739 U.S. Highway 19 N. Insurer B: Holiday, FL 34691 Insurer C: Insurer D: Insurer E: Coverages The es of insurance listed bear have been issued to the Insured named for the policy period Indicated. Notwithstanding any requirement,tern or condition of any crontra or other docunvmt with respect to which this oerttcate may be issued or may pertain,the Insurertoe afforded by the policies described herein is subject to all the terms,exclusions,and conditions of such policies.Aggregate limits shown may have been reduced by paid dabs. INSR ADDL Policy Effective Policy Expiration Limits LTR INSRD Type of Insurance Policy Number Date Date (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence S Commercial General Liability Claims Made 0 Occur Damage occurrence) � promises(EA 8 Med FJ, Personal Adv Injury neral aggregate limit applies per. General Aggregate Policy ❑Project ® LOC Products-Comp/Op Agg UTOMOBILE UABIUTY combined Single Limn (EA Accident) g Any Auto Bodily Injury All Owned Autos (Per Person) Scheduled Autos Hired Autos Bodily Non-Owned Autos (Per Accident) Property Damage (Per Accident) EXCESSIUMBRELLA UABIUTY Each Ocou ate Occur 13claimsMada Aggregate Deductible A Workers Compensation and WC 71949 01/01/2016 01/01/2017 x we Statu- OTH- Employers'Llability to r Limits ER Any proprietor/partner/executive officer/member E.L.Each Accident $1,000,DW excluded? NO E.L.Disease-Es Employee $1,000,000 If Yes,describe under special provisions below. E.L.Disease-Policy Limits $1,000,000 other Uon Insurance Company is A.M.Best Company rated A-(Excellent). AMB#12616 Descriptions of OperadonsiLocadons/Vehicles/Exclusions added by Endorsement/Special Provisions: Client ID: 8x-65-308 Coverage only applies to active employee(s)of South East personnel Leasing,Inc.&Subsidiaries that are leased to the following"Client Company": Nuspace Network,LLC Coverage only applies to Injuries Incurred by South East Personnel Leasing,Inc.&Subsidiaries active employees;,while working in:FL. Coveragedoes not apply to statutory employee(s)or Independent contractor(s)of the Client Company or any other entity. A list of the active employee(s)leased to the Client Company can be obtained by fardng a request to(727)937-2138 or by calling(727)938-5562. Protect Nantes ISSUE 03-17-16(TLD) Bodo Dabs 628 2011 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE Should any of the above described policies be cancelled before the expiration date thereof,the issuing Insurer will endeavor to mail 30 days written notice to the certificate,holder named to the len,but failure to BUILDING DEPARTMENT do so Mail Impose no obligation or liability of any kind upon the insurer,its agents or representatives. 10050 NE 2ND AVE le MIAMI SHORES, FL 33138 �� � NUSPACE NETWORK, LLC 40 SW 13TH STREET OFFICE 10 1 . MIAMI FL 33130 PH.:305 945 3919 F:888 437 6553 March 17, 2016 State of FLORIDA County of MIAMI DADE Building Dept, City of Miami Shores Miami,Florida Re: Robert Netldn Residence Remodeling Before me this day personally appeared Geo Arcia or Franklin Vilchez who being duly sworn,deposes and says: That he or she will be the only person working on the project located at: 1266 NE 94th Street Miami Shores, FL 33138 /1 141 A A /JU- ;,rqa,rio R miano r Sworn to (or affirmed) and subscribed before me this day of �'� . 20-92-, By 09-- By GO. Personally know Type of Identification produced qU ruPI,, `�;'•• BRUGO _ • "= NOW fie- e of Ire W 15.2017 C FF 195 'logo M iami hores illage %—10 ang Building Department R 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 CONTRACTORS' REGISTPATI®N IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. c/ COPY OF QUALIFIER'S STATE LICENCES B. ✓ COPY OF LOCAL BUSINESS TAX RECEIPT COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT, D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 ®rrrmrrearrrrrrerAr1rrrrrrrarrrrrrrrsrrrarrrrrrrrrrrrrrrrrrrarrrasrarrorrrrrrrrrrrrrrrrrrmer BUSINESS NAME: 0,�z?bAcv— �4ck�04 4(2, BUSINESS ADDRESS: l� �C °{t''� 101 CITY t`(�A1�1 STATE FL ZIP BUSINESS PHONE: (_\� CIS �1 FAX NUMBER CELL PHONE t A,-) I� QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: GGC. 062J G 2-j CERTIFICATE OF LIABILITY INSURANCE DATE /YYYl) 033/29/1/29/16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: MARTA ALONSO Florida Bankers Insurance PHONE (305)266-6493 F No): (305)262-0679 7278 SW 8 StreetE-MAILADDRESSO matte@floridabankersinsurance.com Miami,FL 33144 INSURERS AFFORDING COVERAGE NAIC# Phone (305)266-6493 Fax (305)262-0679 INSURERA: LLOYDS OF LONDON INSURED INSURER 13: INFINITY AUTO INSURANCE COMPANY NUSPACE NETWORK,LLC INSURER C: EVASTON INSURANCE COMPANY 40 SW 13 St Suite#101 INSURER D: MIAMI,FL 33130- INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADD UBR POLICY NUMBER POLICY DEFF POLICY YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 © COMMERCIAL GENERAL LIABILITY PAMAGE TO RENTED REM SES(Ea occurrence) $ 100,000.00 A F-17 CLAIMS-MADE Q N N OCCUR L 12/30/2015 12/30/2016 QMH-U MED EXP(Any one person) $ 50,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000.00 0 POLICY ❑ PRO ❑ LOC $ AUTOMOBILE LIABILITY OMBINEntD SINGLE LIMIT 1,000,000.00 a accide © ANY AUTO BODILY INJURY(Per person) $ B ❑ AUTOS ALLOWNED ❑ SCHE ULED N N 509-80001-11875-002 07/1212015 07/12/2016 BODILY INJURY(Per accident) $ NON-OW NED PROPERTY DAMAGE ❑ HIRED AUTOS ❑ AUTOS Per accident $ ❑ ❑ $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ 5,000,000.00 EXCESS LIAs MKLV20LE102690 C ❑ ❑CLAIMS-MADE N N 07/17/2015 12/30/2016 AGGREGATE $ 5,000,000.00 ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑W C STATU- OTH- AND EMPLOYERS'LIABILI Y Y/N TOR Y F-1 ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) LICENSE#CGCO62162 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BLDG DEPT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2nd AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE FAX:305-756-8972 MARTA ALONSO ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD